A Hidden Cost of Covid: Shrinking Mental-Health Services

About 400 psychiatric beds remain closed for care—more such closures than in the past five years, according to the state’s Office of Mental Health. About 150 addiction beds in hospitals are similarly shut, according to the state’s Office of Addiction Services and Supports. The overall number of such beds had risen slightly over the past five years.

Hospitals have also closed behavioral-health beds in other states including Illinois, Massachusetts and Texas, along with Washington, D.C. The closures are pronounced in New York, a state hit hard by the coronavirus.

New York health-care workers described patients being discharged early to free up space even though many still showed signs of psychosis and mania. Some hospitals that kept units open were overwhelmed, they said.

Imani Fecu, 24 years old, who struggled with schizoaffective and bipolar disorder, was discharged from Health + Hospitals/Kings County, a public hospital, days after being admitted in late March.

Her grandmother, Sandra Lindie, along with her caregivers, thought it was too soon for Ms. Fecu to stabilize on new antipsychotic and mood medications. “She crashed and there was no safety net for her crashing,” said Ms. Lindie.

At one time, Ms. Fecu had enrolled in New York University and volunteered teaching JavaScript. She also struggled with heroin and being separated from her incarcerated mother. After her discharge, she rejected her medications and struggled to find a suitable treatment program, say her caregivers, who were reluctant to force her back to the hospital.

On June 25, Ms. Lindie returned to her Brooklyn home with takeout and found her granddaughter dead on the floor. She said police found heroin and a needle in her room. The spokeswoman for the city hospital system declined to comment on Ms. Fecu, citing patient privacy, but said that all decisions were made using expert clinical judgment.

The bed cuts in New York were even higher in the spring and early summer when Covid-19 surged through. That represented the sharpest reduction in the general-hospital psychiatric bed count in at least a decade: 542 beds across 27 hospitals were repurposed or closed—10.6% of such beds—according to the state mental-health office. At least 403 detox and rehab beds in hospitals and community settings were also off-limits, about 13% of total such beds, the state addiction-services office said.

“There are not enough providers, not enough beds, and not enough hands on deck,” said Abby Venzor, a New York therapist whose patient tried unsuccessfully to find treatment at 10 different hospitals.

The state’s mental-health care system was already strained, with bed counts falling as the state closed its psychiatric facilities in favor of community mental-health support and general hospitals cut services.

The closures nationwide have forced more patients to turn to a critical tier of mental-health care—community organizations that help people outside of hospitals—but those groups have struggled to keep up. A September survey of more than 300 such U.S. groups found that 65% had canceled, rescheduled or turned away patients, according to the National Council for Behavioral Health.

Some, including the New York State Nurses Association, worry hospitals will use the moment to close psychiatric units. Inpatient treatment of psychosis costs patients an average $1,351 per bed a day, while a range of common cardiac care costs between $28,000 and $86,000, the group says.

“Behavioral health is the money-losing service line,” said Harsh Trivedi, a board trustee of the American Hospital Association and chief executive of Sheppard Pratt, a private behavioral-health hospital in Maryland. He said steep Covid-related financial losses helped spur U.S. hospitals to close beds.

Poor reimbursement from insurers including Medicaid helped drive nationwide closures even before the coronavirus pandemic, said a spokesman for Westchester Medical Center Health Network, a system that closed beds in suburban New York.

Nationally, no one knows the true number of the recent closures mainly because hospitals moved quickly and didn’t need to offer detailed reporting on the moves, thanks to federal and state waivers allowing the immediate repurposing of behavioral-health beds when the pandemic struck. The federal Substance Abuse and Mental Health Services Administration and several state departments of public health said they didn’t have complete data.

New York’s mental-health office said it expected all beds repurposed to come back online eventually. Agency spokesman James Plastiras said the state had “sufficient capacity” despite the changes and hadn’t received reports of people being denied admission due to pandemic-related closures.

Several hospitals say behavioral-health beds are closed to comply with Gov. Andrew Cuomo’s order that hospitals have a surge plan in case of a second wave of Covid-19. Cuomo administration officials said the order didn’t mandate a certain number or type of beds remain closed for treatment, just that hospitals have a plan in place.

Hospitals say behavioral-health admissions slowed overall, as much as 40% from March through June in Northwell’s case, in part because of fears of catching Covid-19 inside hospitals.

As lockdowns eased, admissions snapped back and are now at pre-pandemic levels, according to the state’s mental-health office. Northwell’s behavioral-health admissions grew 26% in June compared with May; they grew 23% over the same period across New York City’s public health-care system known as NYC Health + Hospitals.

Nurses and psychiatrists say the number of psychiatric and overdose patients has steadily risen in the summer and early fall. They include essential workers such as bus drivers and doctors suffering from post-traumatic stress disorder, as well as recovering Covid-19 patients who have no history of psychosis breaking down.

A spokeswoman for Health + Hospitals said the network hadn’t reached or exceeded its psychiatric-bed capacity. Northwell executives said that the system had no trouble accommodating patients and that most of the offline beds would remain closed for the foreseeable future.

Based on the number of psychiatric beds closed in New York since March, and the length of the average patient stay, the nonprofit Treatment Advocacy Center estimated that 14,000 psychiatric admissions were lost—people who may have needed hospital treatment but weren’t able to get it. “People don’t stop getting sick just because there’s nowhere to treat them,” said John Snook, the group’s executive director.

Closed for care

In the rush to convert beds for critically-ill Covid-19 patients, NewYork-Presbyterian Brooklyn Methodist Hospital closed its two, 25-bed psychiatric units in late March. Several patients who were still psychotic were discharged rather than transferred for continued care, several health-care workers there said.

Emergency medical technician Goldy Landau was called in to help transport patients. One woman had schizoaffective disorder, PTSD, drug-addiction and a history of assaulting staff. Nurses told Ms. Landau that the woman, who was sedated and restrained for the trip, wasn’t ready to go to her group home.

When the woman woke up during the transport, and Ms. Landau explained why she was leaving, she said the woman asked, “All the crazies are going to be walking in the street?”

In Manhattan, NewYork-Presbyterian also closed its Allen Hospital’s 30-bed psychiatric unit, which serves mostly diverse, low-income, Medicaid patients, according to Allen nurse Alana Ribowsky.

Nurses say they since have seen former patients who couldn’t get care now acting erratically on the streets. Irving Campbell, a nurse at NewYork-Presbyterian’s Brooklyn Methodist, said he saw a patient who “at his best is a functional, former engineer,” looking disheveled and picking up cigarette butts off the ground.

The units, which typically see around 1,500 people a year, remain closed. The closures by private hospitals such as NewYork-Presbyterian strained safety-net hospitals such as Nassau University Medical Center on Long Island and those in the Health + Hospitals network as Covid-19 surged in the spring.

NUMC discharged 80 psychiatric patients in 10 days then as it moved to repurpose 56% of its behavioral-health beds, said Constantine Ioannou, NUMC’s chairman of psychiatry. Health + Hospitals hurried to turn 382 behavioral-health beds over for Covid patients.

NewYork-Presbyterian said its “commitment to behavioral health is unwavering” and that it was “working with regulatory agencies on a plan to reopen behavioral health beds in Brooklyn and Northern Manhattan” while remaining prepared for another coronavirus surge.

A similar dynamic was playing out in the suburban counties north of New York City, where the Westchester Medical Center Health Network of 10 hospitals serves several counties.

In the spring, the system closed its Kingston units of 60 psychiatric and drug-recovery beds. Nurses said that patients began backing up in the windowless psychiatric emergency room, forcing some to wait as many as four days for a transfer.

Ulster County Executive Patrick Ryan said he feared the Kingston closures were endangering the community, citing a rise in opioid-overdose deaths. Overall, substance-related fatalities are up 114% through August, and suicides have doubled in the county since March, compared with the same periods in 2019.

Many patients are transferred from Kingston to Westchester facilities between 20 and 90 miles away, including Poughkeepsie’s Mid-Hudson Regional Hospital. Former patients and Kingston nurses reassigned there say discharges were rushed.

Detox nurse Jeri Wessberg filed complaints about improper care with the state. She wrote that staffers once had to use Narcan, an antidote for overdoses, to revive a patient after administering medication doses a doctor had ordered. “This place is unsafe,” said Ms. Wessberg, who said she decided to take an unpaid furlough in September rather than continue to work at Mid-Hudson.

Inadequate supply of basics, like bathrooms and phones, in the new 15-bed overflow psychiatric unit led to brawls between patients, according to more than a dozen former patients and nurses. They said that psychiatric-staffing shortages mean that inexperienced technicians are often caring for patients. The nurses say that has led to excessive “Code Greys”—when security is called and staffers medicate or restrain a noncompliant patient.

The Westchester Medical health system said in a statement provided by spokesman Andrew LaGuardia that patients received high-quality care and were discharged safely. He added that hospitals with behavioral-health services are “experiencing severe staffing shortages.”

Westchester said it was discussing solutions “to maintain, not shrink, current behavioral health bed counts, and expand outpatient behavioral health services.” It said it hadn’t experienced excessive “Code Greys,” longer emergency-room wait times or supply shortages.

System already strained

Most of New York’s behavioral-health bed closures are in New York City, where Covid-19 hit the worst.

Hospital systems there say the closures didn’t result in less treatment because of lower admissions overall. But patients, families and health-care workers say the Covid-19 closures made things worse with a system already under strain.

“We’re hearing from people who, in their hour of need, are being turned away from hospitals, discharged prematurely, or forced to stay in facilities far from their homes,” said Matt Kudish, executive director of NYC’s chapter of the National Alliance on Mental Illness, which has heard from many families.

Mental-health care workers at the city’s Rikers Island jail complex say that some detainees released during the pandemic were coming back in after committing crimes. “They can’t get services when they get out and they are sick,” said Alicia Butler, a Rikers psychiatric nurse.

Robert Memory, a former community health worker who sought help in July at Montefiore Medical Center’s Bronx emergency room, said he was discharged too early and tried two days later to overdose on pills and alcohol. “I was in a deep dark place with the pandemic and no support,” except a cat, said Mr. Memory.

When he sought care at Montefiore, he was transferred to Brunswick Hospital Center on Long Island. He said the ambulance worker told him there were no other beds in New York City.

A Montefiore spokeswoman declined to comment on Mr. Memory’s account, citing patient privacy.

Nassau University Medical Center on Long Island was among the hospitals during the spring surge that under new federal and state rules could quickly pivot behavioral-health beds for coronavirus patients.

One of the patients it discharged in the summer was Nurys Caceres’s 22-year-old son—released after 10 days, she said, “in a full mania.”

She said the spring of isolation was “the kiss of death” for her son, a former Stony Brook University student diagnosed with bipolar disorder and depression.

In late July, Ms. Caceres called police after her son stormed out of the house, saying he planned to jump in front of a train. He was taken to NUMC. He was discharged 12 hours later, but Ms. Caceres said the hospital didn’t tell her.

Police found him four days later in Harlem. They got him to Health + Hospitals/Harlem, which transferred him to Brunswick on Long Island, Ms. Caceres said. That hospital discharged him in 10 days, unstable and rejecting the lithium they had prescribed, his mother said.

“The patients that are coming through the doors are 100% more extreme and acute than have ever been through the doors before,” said Mike Devery, Brunswick’s chief quality officer, who declined to comment on individual patients. He said the hospital hasn’t felt pressure to discharge early and many patients have had successful outcomes.

Within weeks, Ms. Caceres said, her son took all his lithium pills in an attempt to kill himself and wound up back at NUMC.

Dr. Ioannou, the NUMC psychiatry chairman, said the hospital began reopening beds in late July, but with a slightly lower capacity because of coronavirus-related precautions.

He declined to comment on patient cases, but said that coronavirus restrictions had strained communications with families and that discharges were hard on them because “outpatient programs are still more or less shut down.”

He said the hospital often kept patients longer than others do and took pride in helping those without resources. “You’re going to have outcomes that are perhaps a little worse and you’re going to have complicated cases,” he said. “There is nothing worse than watching a child suffer.”

—Joe Palazzolo contributed to this article.

Write to Shalini Ramachandran at [email protected]